Mitigating the risk of respiratory infection outbreaks in crowded nursing homes in Hong Kong
Authors: Lina Chow
Journal: The Lancet Healthy Longevity (2023)

In The Lancet Healthy Longevity, Pamela Leece and colleagues1Leece P Whelan M Costa AP et al.Nursing home crowding and its association with outbreak-associated respiratory infection in Ontario, Canada before the COVID-19 pandemic (2014–19): a retrospective cohort study.Lancet Healthy Longev. 2023; 4: e107-e114Summary Full Text Full Text PDF Scopus (2) Google Scholar report that a high crowding index is associated with an increased risk of respiratory infection outbreaks in care homes. However, this increased risk can be mitigated by means other than reducing crowding, if circumstances do not permit such a reduction. In Hong Kong, nearly all care homes have a high crowding index. Four-person or six-person bedrooms are a common design in government-funded care homes. Most private care homes have an open floor plan, where bedspaces are separated by low partitions.2Chow L Care homes and COVID-19 in Hong Kong: how the lessons from SARS were used to good effect.Age Ageing. 2021; 50: 21-24Crossref PubMed Scopus (22) Google Scholar Because property prices and rent costs are very high, reducing crowding in care homes in Hong Kong is largely impossible. In response to the outbreak of severe acute respiratory syndrome in 2003, the Hong Kong government implemented, in 2007, measures to minimise the risk of outbreaks of communicable diseases in care homes.3Centre for Health Protection Hong KongGuidelines on prevention of communicable diseases in residential care homes for the elderly.https://www.chp.gov.hk/files/pdf/guidelines_on_prevention_of_communicable_diseases_in_rche_eng.pdfDate accessed: March 28, 2023Google Scholar First, every care home must appoint an infection control officer. Second, to mitigate crowding issues, care homes must maintain good indoor ventilation by means of natural methods, such as open windows, or mechanical methods, such as extractor fans. The proposed standard for fresh air replacement is at least 0·43 m3/min per person.4Centre for Health Protection Hong KongA supplement on ventilation. Guidelines on prevention of communicable diseases in residential care homes for the elderly & guidelines on prevention of communicable diseases in residential care home for persons with disabilities.https://www.chp.gov.hk/files/pdf/a_supplement_on_ventilation.pdfDate accessed: March 28, 2023Google Scholar Third, care homes must monitor the health conditions of residents and staff closely to allow for early detection of outbreaks. Fourth, whenever a resident shows symptoms of respiratory infection, they must wear a surgical mask until symptoms resolve. Fifth, residents with respiratory symptoms must be isolated in an individual room, or partitions must be used to separate them from other roommates. Sixth, staff and visitors must wear surgical masks in care homes when a resident has respiratory symptoms. Seventh, to avoid cross-infection, the same group of staff should care for the same group of residents. These measures were very effective at containing the spread of SARS-CoV-2 before the emergence of the omicron strain in February, 2022.2Chow L Care homes and COVID-19 in Hong Kong: how the lessons from SARS were used to good effect.Age Ageing. 2021; 50: 21-24Crossref PubMed Scopus (22) Google Scholar From January, 2020, to July, 2021, less than 200 residents in 40 care homes in Hong Kong had COVID-19, even though the vaccination rate of residents was very low.2Chow L Care homes and COVID-19 in Hong Kong: how the lessons from SARS were used to good effect.Age Ageing. 2021; 50: 21-24Crossref PubMed Scopus (22) Google Scholar These measures are also effective to prevent other respiratory infection outbreaks. Only 90 influenza outbreaks occurred in care homes in Hong Kong in 2018, and 98 outbreaks in 2019,5Centre for Health Protection Hong KongFlu express.https://www.chp.gov.hk/en/resources/29/304.htmlDate accessed: March 28, 2023Google Scholar which are modest numbers considering that Hong Kong has 1069 care homes. Furthermore, no influenza outbreaks occurred in care homes in Hong Kong between Feb 16, 2020, and Jan 28, 2023.5Centre for Health Protection Hong KongFlu express.https://www.chp.gov.hk/en/resources/29/304.htmlDate accessed: March 28, 2023Google Scholar The Hong Kong circumstances show that appropriate measures can be effective in preventing outbreaks of respiratory infection in care homes—even in conditions of high crowding. I declare no competing interests. Nursing home crowding and its association with outbreak-associated respiratory infection in Ontario, Canada before the COVID-19 pandemic (2014–19): a retrospective cohort studyRespiratory infection and mortality rates were higher in nursing homes with high crowding index than in homes with low crowding index, and the association was consistent across various respiratory pathogens. Decreasing crowding is an important safety target beyond the COVID-19 pandemic to help to promote resident wellbeing and decrease the transmission of prevalent respiratory pathogens. Full-Text PDF Open Access